﻿<%@ Page Title="" Language="C#" MasterPageFile="~/Views/Shared/Site.Master" Inherits="System.Web.Mvc.ViewPage" %>

<asp:Content ID="Content1" ContentPlaceHolderID="MainContent" runat="server">

 <div class="why">
       <div class="refund">
               <b class="review_lf_t"><b class="review_lf_tl"></b><b class="review_lf_tr"></b></b>
               <b class="refund_f">
               <div class="refund_a">
                       <h1 class="title_h1">Please Fill In The Following Details</h1>
                   </div>
               <div class="refund_b">
               		<ul class="title_a">
              			<li>What name would you like your Cognicoach to call you?</li>
                        <li>Date of birth:</li>
                        <li>Cender:</li>
                        <li>Education:</li>
                        <li>Are you right-handed or left handed?</li>
                        <li>Computer usage:</li> 
                        <li>Health condition:</li>
                        <li>Do you have problems distinguishing between colours?</li>
                        <li>Country:</li>
                        <li>What type of driver's licence do you have?</li>
                        <li>Please indicate how many years you have been  driving?</li>
                        <li>Please indicate how many miles you drive each month?</li>
                        <li>Which of the following sports do you prefer?</li>
                   		<li>How often do you engage in physical activity?</li>
                    	<li>How many hours do you usually sleep at night?</li>
                    	<li>Do you consume alcohlic beverages?</li>
                    	<li>Do you take medication on a regular basis?</li>
                        <li>What is you occupational field?</li>
                        <li>Do you fell any change in you driving recently or over the<br />
                        	past few years?
                        </li>
                    </ul>
                    <ul class="text">
                    	<li><input type="text" class="txtbox" /></li>
                        <li class="sel_a">
                        	<select><option>Day</option></select>
                        	<select class="li_a"><option>Month</option></select>
                            <select class="li_a"><option>Year</option></select>
                        </li>
                        <li>
                        	<input type="radio" name="sex"/>Male
                            <input type="radio" name="sex" class="li_a"/>Female
                        </li>
                        <li>
                        	<input type="checkbox"/>Less than x years
                            <input type="checkbox" class="li_a" />x years
                            <input type="checkbox" class="li_a" />x to x years
                            <input type="checkbox" class="li_a" />More than x years
                        </li>
                        <li>
                        	<input type="checkbox"/>Right handed
                            <input type="checkbox" class="li_a" />Left handed
                        </li>
                        <li>
                        	<input type="checkbox"/>Daily
                            <input type="checkbox" class="li_a" />Occasional
                            <input type="checkbox" class="li_a" />About ones a week
                            <input type="checkbox" class="li_a" />Never
                        </li>
                        <li>
                        	<input type="checkbox"/>Generally healthy
                            <input type="checkbox" class="li_a" />Some health probleams
                            <input type="checkbox" class="li_a" />Serious heath problems
                        </li>
                         <li>
                        	<input type="checkbox"/>No
                            <input type="checkbox" class="li_a" />Yes

                        </li>
                        <li>
                        	<select class="sel_b"><option>select</option></select>
                        </li>
                        <li>
                        	<select class="sel_b"><option>select</option></select>
                        </li>
                        <li>
                        	<select class="sel_b"><option>select</option></select>
                        </li>
                        <li>
                        	<select class="sel_b"><option>select</option></select>
                        </li>
                        <li>
                        	<select class="sel_b"><option>select</option></select>
                        </li>
                        <li>
                        	<select class="sel_b"><option>select</option></select>
                        </li>
                        <li>
                        	<select class="sel_b"><option>select</option></select>
                        </li>
                        <li>
                        	<select class="sel_b"><option>select</option></select>
                        </li>
                        <li>
                        	<select class="sel_b"><option>select</option></select>
                        </li>
                        <li>
                        	<select class="sel_b"><option>select</option></select>
                        </li>
                        <li>
                        	<select class="sel_b"><option>select</option></select>
                        </li>
                    </ul>
                    <div class="middle_bottom">
                  		<label><input type="submit" name="button" id="button" value="" /></label>
                        <em><input type="submit" name="button2" id="button2" value="" /></em>
                    </div>
               </div>
               </b>
               <b class="refund_d"><b class="refund_dl"></b><b class="refund_dr"></b></b>
           </div>
    </div>
</asp:Content>
